The emphasis on biomechanics in podiatric education has been the subject of debate recently due to potential changes in the CPME 320 residency requirements. In a recent Podiatry Today online poll, 65 percent of poll respondents said there is not enough focus on biomechanics in podiatric education.
Several DPMs who posted comments on the online poll were vocal in their opinion that podiatry schools and residency programs need to pay more attention to biomechanics. Doug Richie Jr., DPM, says every podiatry school should have a full-time faculty member who has a PhD in biomechanics and has published research in the field of lower extremity biomechanics.
"These individuals have paved the way with our new understanding of lower limb function, which has huge implications for surgical planning as well as foot orthosis prescription," says Dr. Richie, an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University.
Furthermore, Dr. Richie notes that schools too frequently have teachers with "little clinical experience and no research accomplishments in the biomechanics arena." He maintains that the faculty should include seasoned clinicians who can integrate the current body of knowledge of foot orthotic therapy into the biomechanics curriculum.
Dr. Richie also suggests that biomechanics instructors must stay current with research published in non-podiatric journals and attend meetings in disciplines outside of podiatry. He notes that the physical therapy and athletic trainer disciplines are contributing the bulk of the new research in the field of lower extremity biomechanics. Dr. Richie says experienced faculty in this arena would be able to interpret this research and make it applicable to the podiatric curriculum.
How A Lack Of Biomechanical Knowledge Can Lead To Incorrect Surgical Choices
Jared Frankel, DPM, says one cannot be an accomplished podiatric surgeon without a strong understanding of the biomechanics of the lower extremity.
"You cannot teach surgical care of the human foot without the goal of restoring function. An understanding of function does not come without an understanding of the biomechanics of every joint in the foot and its interrelationship to every other joint in the foot and body," says Dr. Frankel, who is in private practice at Elmhurst Podiatry Center in Elmhurst, Ill.
For example, Dr. Frankel says understanding the axis of motion of the first ray and how it changes in hallux valgus formation would be of central importance in selecting an appropriate procedure that restores motion.
As Dr. Frankel suggests, without knowledge of foot function, a DPM might think it acceptable to perform a metatarsal head resection for a plantar callus, a Keller bunionectomy for hallux valgus or a fifth metatarsal head resection for a tailor’s bunion on a 15-year-old patient with a splay foot as podiatrists did in the 1970s.
Dr. Frankel says a lack of biomechanical knowledge might also lead surgeons to perform osteotomies on all five metatarsals for the treatment of a flexible forefoot valgus with diffuse callosities of the forefoot as "minimal incision surgeons" advocated in the 1980s. A surgeon without a biomechanical background would have no idea that this was an ill-conceived surgical plan due to the destruction of the weightbearing ability of the foot and impaired biomechanics, according to Dr. Frankel.
"I do not think our schools of podiatric medicine appreciate this nor do residency programs require this knowledge," says Dr. Frankel. "If we are going to train the innovative surgeon, not the cookbook surgeon, this knowledge is essential in advancing surgical care."
Suggestions For Improvement
Proposed changes in the CPME 320 residency requirements would mean residents would be exposed to fewer clinical encounters in biomechanics in favor of more rearfoot surgical procedures, according to Dr. Richie.
"Nearly all rearfoot surgical procedures must have a biomechanical rationale and this would be a perfect opportunity to integrate biomechanics into surgical residency training," says Dr. Richie. "A simple protocol which requires a biomechanical assessment of each and every rearfoot surgical case should be mandated if the proposed changes are approved."
Dr. Richie also suggests that residency programs require residents to be exposed to a gait lab sometime during the program. Residency programs should require a valid clinical rotation, which involves hands-on application of foot orthotic therapy, ankle foot orthoses, footwear modification and physical rehabilitation, according to Dr. Richie. He also advocates mandating some type of research that focuses on one of the many subject areas of lower extremity biomechanics, such as kinetics, kinematics, neuromuscular control, foot orthotic therapy or gait training.
Dr. Frankel offers similar sentiments.
"Biomechanics must be more than one or two courses in podiatry schools," says Dr. Frankel, a Fellow of the American College of Foot and Ankle Surgeons.
In addition to a need for increased course curriculum in this area, Dr. Frankel says biomechanics training must also encompass and encourage investigative research.
What should one say to a young student/resident who believes he or she can practice podiatry without understanding biomechanics? Dr. Richie would ask such students to open any issue of Foot and Ankle International. He says there is an emphasis on original biomechanical research in this journal with quality articles that have "direct relevance to foot and ankle surgery."
Dr. Richie also offers an analogy: "How can a mechanic fix a car when he does not even know how the car works?"